Americans Filching Free Health Care in Canada

By CLYDE H. FARNSWORTH,

Published: December 20, 1993

TORONTO, Dec. 19—
Lacking a national health care system of their own, thousands of Americans are tapping into Canada's -- illegally.

"It's not an epidemic in any one person's practice," said Keith MacLeod, an obstetrician in Windsor, Ontario, across from Detroit, "but I would estimate that from 12 to 20 of my patients at any one time are ineligible Americans. And I'm just one of 520 doctors in Windsor, 23,000 in Ontario."

Dr. MacLeod, former president of the Essex County Medical Society, delivers about 400 babies a year.

A report prepared for Ontario's Health Minister indicated that from August 1992 to February 1993, 60,000 medical claims had been made on behalf of patients who held American drivers' licenses. The total number of improper claims in Ontario was estimated at 600,000.

Only legal residents qualify for free medical care in Canada, using plastic health cards for identification. Others are supposed to pay for medical services they may require, but many are submitting counterfeit, borrowed or fradulently obtained cards.

Loopholes and the lack of stringent controls are costing the provincial health care system as much as $691 million a year, the Ontario report found.

"The ministry is open to the fraudulent use of health care in all programs," the report said. "Almost no analytical tools exist at this time, and lenient registration policies encourage abuse by non- and new residents."

Joseph Cordiano, chairman of the Public Accounts Committee of the Ontario Legislature, added, "Fraud is squandering our resources."

Although the encroachment is largely a border phenomenon, it has national scope because more than 90 percent of Canadians live and work within 100 miles of the United States. Other provinces have similar problems, but Ontario's size has given the issue national prominence.

In Canada, policing health care was always seen as more trouble than it was worth, and the authorities have long ignored cracks in the system. Doctors have little desire to be secret informers, and strict patient confidentiality laws have helped seal their lips.

And for years Canadians widely believed that their country was rich enough to look after all those who entered its portals.

But times are changing. In an era of mammoth budget deficits, to which free health care is a leading contributor, politicians of all stripes are eagerly seizing on ways to save money.

"In the past, we didn't pay enough attention to who was an Ontario resident," said Health Minister Ruth Grier, a member of the socialist-oriented New Democratic Party, which governs the province. "But now we have to make sure that we spend taxpayers' dollars as wisely as possible."

The provinces run Canada's health care system, which takes roughly a third of their budgets and is financed by payroll taxes, federal transfer payments and periodic borrowing.

About a quarter of the $17 billion spent on health care in Ontario, the richest and most populous province, is borrowed in the form of bonds sold to investors, many from the United States. Borrowing Costs Increase

The recent downgrading of Ontario's debt by two leading bond-rating services has suddenly raised the province's borrowing costs, thus compounding its financial problems.

Many reasons besides fraud contribute to Canada's rising medical costs: higher prices for medical technology, relatively long hospital stays and an oversupply of doctors, who are rewarded under a fee-for-service system when they see more patients and perform more procedures.

Yet fraud has drawn the spotlight, perhaps because it is an easier political target than some of the other factors.

Jim Wilson, the spokesman on health matters for the Conservative opposition in Ontario's Legislature, is urging stiffer verification procedures.

"We've lost 5,000 hospital beds in the last two years," he said. "There are ever-increasing waiting lists for cancer treatment. There is a health care crisis in Ontario, and the public has very little patience for Americans or others not entitled to use our health system clogging up our services."

All it takes to get free health treatment is a little plastic card. Doctors and hospitals note the number on the card and bill the province according to a fee schedule. In Ontario the card is red and white, bears no photograph and gives the name, date of birth and sex of the holder. Only the holder is entitled to the medical services. More Cards Than Residents

A recent report by the Provincial Auditor's office found 10.5 million Ontario residents registered to receive health care. The province has a population of 10 million.

Some evidence exists that cards are counterfeited. In drug and other raids, the police have confiscated cases of blank health cards. Also, families often fail to turn in cards of people who die.

As the card provides little information, borrowing is relatively easy for someone of the same sex and about the same age as the holder.

In June, Tommy Bettis, from Arkansas, broke his arm and cut his head while helping to repair the garage of a friend, Kristopher Goering, in Thorold, a small Ontario community between St. Catherines and Niagara Falls.

When Mr. Bettis received emergency-room care at St. Catherines General Hospital, he presented Mr. Goering's card, the authorities said.

What they say is a similar incident occurred in August in Kingston, about 150 miles east of Toronto. Sandra Skinner, from Rochester, N.Y., fractured her elbow and used the card of a friend, Brenda Jean Cripps of Kingston, to pay for treatment in the emergency room of the Hotel-Dieu Hospital.

These are among the first cases in Ontario history in which formal charges of health card fraud have been brought. They are part of a new crackdown, said Mrs. Grier, the Health Minister. Hospital staff members alerted the authorities in both cases. Penalties for Fraud

The charges against the two Americans were fraud and impersonation. The maximum penalty for fraud is 10 years in prison; for impersonation, 14 years. The two Canadians were accused of being parties to an attempted fraud, which is also a criminal offense but which carries lesser penalties.

The Bettis-Goering case will be heard on Dec. 21. The Skinner-Cripps case ended in an "absolute discharge," meaning no records are kept of the offense, after the emergency room bill was settled and both women pleaded guilty.

These were emergencies involving Americans visiting Canada. Yet doctors report that many Americans are poaching as a normal routine.

"They are people with an Ontario address for OHIP" -- Ontario Health Insurance Plan -- "but an American telephone number and place of employment," said Dr. MacLeod of Windsor.

Some are Americans who were able to obtain health cards years ago by virtue of summer cottages they owned in Canada. Only full-time residents are legally entitled to use the cards. Some routinely borrow health cards of Canadian friends.

Michael Decter, Ontario's Deputy Health Minister, said in testimony in the fall before Mr. Cordiano's committee, "I expect you will see a lot more charges laid." Collection Efforts Planned

As part of the crackdown, officials said, cards of ineligible users will be seized and efforts made to collect for the medical services provided.

"Our intention is not to send thousands of Americans to jail," said Anne Moon, corporate services manager for the Ontario ministry, "but to get them to pay their bills.

"Anyway, we hope it's a temporary phenomenon, until President Clinton gets his health plan through."

Among other measures being considered to deal with the fraud are more rigorous verification and control procedures and a new card that may carry more information and include the bearer's photo.

Not all abuse is by Americans. Dr. Kevin Moran, a general practitioner, said he routinely sees fraud where he works in the emergency rooms of the Scarborough General Hospital and the Centenary Health Center. Scarborough, part of metropolitan Toronto, is the home of many immigrants, legal and illegal, from such countries as India, Sri Lanka and Jamaica.

Legal immigrants are entitled to health cards; illegal immigrants are not. Dr. Moran spoke of a recent case in which a 15-year-old boy produced the health card of a person over 40. "If you're working late at night, you certainly don't confront anybody," he said.

Yet as part of the Health Ministry's tougher stand, doctors may well have to do more screening. Under a bill the New Democratic government is pushing through the Ontario Legislature, if a doctor has reasonable grounds to believe that a health card is being used fraudulently, he or she is relieved of liability on confidentiality grounds and must report the fraud.

But the corrective actions may not work very swiftly or effectively. Mr. Wilson, the Tory health spokesman in the Ontario Legislature, noted:

"Canada is an easy route for the Americans. If they can find a health card, they have a very good chance of using that card undetected for as long as the party lasts, and the party certainly won't be over tomorrow."

Photo: "If you're working late at night, you certainly don't confront anybody," said Dr. Kevin Moran, a general practitioner, who routinely sees fraud in the emergency room where he works in metropolitan Toronto. (Carlo Allegri for The New York Times) (pg. A8) Map of Ontario, Canada (pg. A8)